Discussion

Nice article !! I only suggest to include a note saying that ketamine should be avoided in agitation do to TBI or stroke, because it enhance oxygen consumption in the brain and increase damage.
Greetings !!

I’d suggest you read this piece…
Myth: Ketamine should not be used as an induction
agent for intubation in patients with head injury
Yevgeny Filanovsky, MD;* Philip Miller, MD;† Jesse Kao, MD‡
CJEM 2010;12(2):154-7

Here is the conclusion:
Based on its pharmacological properties, ketamine
appears to be the perfect agent for the induction of
head-injured patients for intubation. The evidence for
neuroprotection in humans remains inconclusive at
this time. However, more recent prospective data
examining ketamine usage as a sedative agent in
patients treated with mechanical ventilation suggests
that there is no association with increased ICP in head
injury.
Despite limited evidence specific to its use as an
induction agent, we feel that additional consideration
must be paid to the possible usage of ketamine for RSI
in patients with head injury, especially when alternative
agents that do not cause hypotension are unavailable.

this could be made to work with many sedative agents, but I can’t recommend any of them, b/c the potential to screw-up is much higher. It doesn’t mean you could not do this with propofol, etomidate, or versed; it just means it is tougher and riskier. The other problem is that the sedative dose for the preox will not be the same as the induction dose for the intubation with these other agents.

However, the RSA technique differs in that they take away protective reflexes in order to place an NG-loaded LMA Supreme to facilitate preoxygenation prior to ETT attempt of a suspected difficult airway.

Great work as always Scott – waiting for the next blue, agitated patient to come in. For those of us without easy access to droperidol – is there much difference between droperidol and haloperidol in practice?

Scott: Can you comment on the use of Ketamine and DSI in the Excited Delirium patient (specifically PCP, Cocaine, Bath Salt toxicity). Handcuffed, profusely diaphoretic, tachycardic, highly agitated and uncooperative. Thanks.

I am especially interested in the subset of patients who get ketamine or precedex and then improve and don’t require intubation. There seem to be a subset of patients with asthma or COPD who get into a vicious spiral of (anxiety ==> hyperventilation ==> autoPEEP & gas trapping ==> ineffective ventilation ==> anxiety, etc). I’ve had a lot of success with precedex gtt + BiPAP in this situation to help them slow down their respiratory rate enough to ventilate effectively (and avoid intubation). It needs to be done on carefully selected patients with extreme vigilance but so far I’ve gotten lucky. Any thoughts on this?

You ever had a really hypoxic, precarious patient such as the one described by Josh Farkas who also had a particularly difficult looking airway? Did you ever in those cases think about trying video laryngoscopy with the ketamine on board while the patient is breathing thereby avoiding the paralyctic altogether? Gentle peak with the glidescope for example?

I had a patient the other night come in with flash pulmonary edema, but also febrile from a nursing home. Wasn’t sure if it was his CHF or ARDS, but he looked awful. Despite CPAP of 5 by prehospital care, his sat on arrival was 89%.

Now in the past, prior to following your practice suggestions, I would have just tubed him then and there. Just said screw it, CPAP isn’t working, he’s still hypoxic and tachypneic and barely responsive.

But I didn’t because I’m smarter than that thanks to your podcast! I put him on BIPAP instead, bumped his expiratory pressure up a bit, got his sat about 96%, left him there for a few minutes, then did passive oxygenation by nasal cannula. It took the resident about 45 seconds to get the tube, but the patient never desat’d below 95%. It would have been a really different story had we started with a pulse ox of 89%. What could have been a crash airway disaster went as smooth of an RSI as you could get.

I didn’t have to use ketamine, so technically not DSI, but the concepts the same, using NIV positive pressure ventilation to preoxygenation.

Hi Scott – thanks for all your work with the website very useful stuff. Recently I used DSI to successfully intubate a non resolving post-ictal patient (sidenote – I am a critical care flight Paramedic not a Physician). Worked great in a patient that was trending towards the airway death spiral 500+ statute miles from the closest hospital.

Scott,
I love the DSI concept. However, because there is very little negative discussion of the concept I would like to share that I had a case recently in a child.

I administered Ketamine to a 2 year child with bleeding profusely after eschar sloughed from T&A procedure. Child had borderline sats and was placed on nasal cannula oxygen, NRB and administered Ketamine. Shortly after Ketamine administration patient vomited copious amounts of swallowed blood obscuring the airway and making for a difficult intubation

Is there some inherent risk in the ‘delay’ portion of DSI of losing the airway to stomach contents? Is the RSI concept not based upon this risk of vomiting during airway manipulation?

not in adults, which is the only area I have ever advocated DSI. Adults have never had a case of periprocedural vomiting in the literature from ketamine. Kids definitely have.

RSI is based on no positive pressure ventilation to avoid vomiting. DSI also avoids this. Kids can definitely vomit from ketamine during the procedure. While there has one been one case of Peds DSI in the literature, I do not treat children and can’t advocate the practice in a cohort I know very little about. Thanks for sharing the case.

Thank you scott for your lecture I learned alot !!!
I need to ask you did you have the chance to publish your case series ?
I would like to bring DSI topic to ecommunity chest network for further discussion if possible ….

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Hi, my name is Scott Weingart. I am an ED
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